Fetal Circulation and Transition To Extra-Uterine Life

The development of a human baby from a singular cell (one ovum unites with one sperm to form the zygote, the name given to fertilized ovum) and the subsequent transition from intra-uterine to extra uterine life is one of the many wonders of creation. It is to be remembered that the fetus cannot get atmospheric oxygen but is nourished by oxygen from the mom straight through the placenta. In order to perform this, the fetus has a mechanism which would be very abnormal in extra uterine life. To understand this, first we need to understand the normal circulation in adults.

The heart is a four chambered organ. The two upper chambers are called atria-left and right. The two lower ones are called ventricles -left and right. The 2 atria are completely separated by a buildings called inter-atrial septum. Similarly the ventricles are separated by the inter-ventricular septum. Thus blood in the left side of the heart is completely separated from the blood in the right side. The right atrium receives blood from all the organ of the body straight through two main blood vessels-the excellent vena cava and the inferior vena cava and then pumps that blood into the right ventricle. This blood is depleted of oxygen.

The right ventricle pumps this blood into the lungs straight through a blood vessel called pulmonary artery, which divides into two one each for a lung. The main artery goes on dividing and subdividing till it reaches the sac like structures in the lungs called alveoli. The total outside area of alveoli is approximately equal to the size of a tennis court. In the alveoli gas exchange takes place-carbon-dioxide is thrown out and oxygen is taken up by the blood. The exiguous blood vessels carry oxygenated blood into progressively larger blood vessels and finally this blood comes to the left atrium straight through four pulmonary veins. From the left atrium oxygenated blood enters the left ventricle straight through the left atrio-ventricular valve. The left ventricle then pumps blood into a big blood vessel called aorta. This gives off branches and supplies oxygenated blood to all the cells of the body-the whole process is no less complex than the water contribute and drainage law of a town! Blood from the cells is again returned to the right atrium thus completing the cycle. The cycle goes on and on till the end of life.

This can never work in a fetus because there is no direct passage to atmospheric oxygen. Nature has devised a marvelous mechanism to contribute oxygen to the fetus. The umbilical cord which forms the link in the middle of the mom and the fetus and is cut after birth, contains a blood vessel called umbilical vein. This vein carries oxygenated blood from the placenta into fetus. This divides into two inside the body of the fetus one subject goes to the liver and the other called ductus venosus joins inferior vena cava, which carries deoxygenated blood to the right atrium. From this point the fetal circulation is different. As this oxygenated blood has to be supplied to all the fetal cells it has to go to the left side of the heart. There is no point in pumping it to lungs, which cannot carry out gas exchange. The inter-atrial septum in the fetus consists of two overlapping layers. They overlap in such a way that blood from the right atrium can enter the left atrium but the reverse cannot take place (valve like mechanism). The pressure in the right side heart in the fetus is higher than the left-exactly opposite to that after birth. Hence most of this blood goes into the left atrium, then to the left ventricle and pumped into aorta.

The right atrium also receives deoxygenated blood from the upper parts of the body straight through the excellent vena cava. This blood mixes with blood from the inferior vena cava (which carries blood with higher oxygen concentration) enters the right ventricle and then pumped into the pulmonary artery. In the fetus the pulmonary artery is related to the aorta by a blood vessel called ductus arteriosus. Because there is no point in pumping blood into the lungs most of the blood in the pulmonary artery in shunted over the ductus arteriosus into the aorta. This blood contains less oxygen than that pumped by the left ventricle and supplies the lower parts of the body. The umbilical cord also contains two umbilical arteries. These arteries consist of deoxygenated blood from the fetus into the placenta completing the cycle.

Soon after birth the umbilical cord is clamped and cut. This increases resistance to systemic blood flow and raises the pressure in the left side of the heart. At the same time pulmonary pressure falls as air enters the lungs of the baby with the first breath. This stops the right to left shunting of blood over the atria. As the pressure in the aorta goes above that of pulmonary artery the shunt over ductus arteriosus gets reversed and some blood flows from the aorta into the pulmonary artery. But the ductus arteriosus starts shrinking and functionally closes by about 72 hours of life and anatomically closes within a few weeks. Thus the mixing of blood in the middle of the two sides of the heart completely stops and the usual adult type of blood circulation is established.

Another unique feature of the fetus is the presence of a dissimilar type of hemoglobin called fetal hemoglobin. This differs from the adult hemoglobin in that it has higher affinity for oxygen than the adult hemoglobin. Hence it is able to take up hemoglobin from the maternal hemoglobin and deliver it to fetal cells. It can be observed that fetal cells get blood with lower concentration of oxygen than adults do because of mixing of blood in the two sides of the heart. The fetus is able to survive in spite of low oxygen concentration because the maternal body takes care of many functions and the energy requirement is lower. After birth the concentration of fetal hemoglobin falls rapidly and that of adult hemoglobin increases. Thus nature ensures that the fetus develops inside the uterus by getting oxygen from the mom and soon after birth starts utilizing atmospheric oxygen straight through a complex mechanism. It is indeed marvelous that for the vast majority of newborns the transition is smooth.

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Hip replacement Complications

Close to 200,000 hip replacement surgeries are performed each year in the United States. Over 90% are victorious with no hip replacement complications while or after surgery. But as with all surgeries, the risk of complications is always a possibility. However, complications are infrequent and often reversible.

The older the someone is the higher the risk of complications. A someone over 80 years old has a 20% opportunity of developing at least one complication after hip replacement surgery.

Hip replacement complications while surgery

Nerve damage

The sciatic nerve is at risk of being accidentally surgically cut due to its close nearnessy to the capsule of the hip joint. This same nerve may also become over-stretched while hip manipulation while surgery.

Depending on the extent of the nerve damage, temporary or permanent damage may result. There may be loss of muscle power and feeling in parts of the leg. It may take up to 6 months or more for recovery. Most patients have some paralysis nearby their incision site which may be permanent.

Vascular damage

The damage involves direct trauma to the blood vessels in the area of the surgery. The damaged blood vessel can be repaired by a vascular surgeon if it is caught in time.

Femur fracture

Force is applied while the surgical procedure. This can effect in a femoral shaft fracture, especially in older or osteoporotic patients. Again, the problem is addressed while surgery, but may lead to extended rehabilitation. The surgeon may place weight bearing restrictions while you are walking.

Leg distance discrepancy

In some cases, it may be difficult to get the exact same leg lengths. The effect is regularly a longer leg on the surgical hip. It may be confident and deliberate in order to enhance muscle function or stabilize the hip. If there is more than a quarter of an inch difference, a shoe lift may be necessary.

In some patients, both legs are the exact same distance but they think their surgical operation leg "feels" longer. In most cases this "feeling" goes away as the sick person adjusts to their new hip.

Rarely does shortening of the leg occur. If the leg is significantly shortened after surgery, it may have dislocated.

Anesthetic complications

Complications can occur, and in rare cases even death. Your anesthesiologist will construe the risks complex prior to your surgery.

Hip replacement complications after surgery

Blood clots (Dvt-deep vein thrombosis)

This is one of the most common complications after hip replacement. The most common area is in the calf. Increased leg pain is regularly the most confident symptom. Blush nearby the area of the clots may also occur. It's a minor problem if the clots stay in the leg. But if they dislodge, they can reach the lungs (pulmonary embolism) and can perhaps effect in death (very rarely).

If your surgeon suspects blood clots, he will immediately order an ultrasound to confirm or rule out clots. Most surgeons will order bed rest until the test results come back confident or negative for blood clots. He will prescribe a blood thinner. Compression boots and ankle/leg exercises help reduce the opportunity of blood clots.

Infection

Infection can occur while surgical operation or fabricate afterwards. It is one of the most serious risks to the joint replacement. If the infection settles deep into the joint and surrounding tissues, the new joint often has to be removed until the infection clears with treatment. If the sick person develops an infection elsewhere in the body (bladder, teeth, chest), it must be controlled to preclude the possibility of it spreading through the blood to the new joint.

If you have rheumatoid arthritis or diabetes, or have been taking cortisone for a long time, you are more prone to infection in the weeks following your surgery.

Infection can occur many years after the surgery. Bacteria can tour through the bloodstream from an infection in other parts of your body (bladder infection, infected wound, kidney infection). Oral antibiotics may need to be taken before and after habit dental work years after your hip replacement operation.

Hip dislocation

The first six weeks after hip replacement is the most vulnerable time for your new hip. while this period, muscle tension is the only thing holding the metal ball in the socket. If the metal ball slips out of the socket, it's dislocated. As the hip muscles fetch their force and scar tissue forms nearby the ball, the risk of hip dislocation diminishes.

Traditional hip replacement requires that confident precautions be taken and some positions/movements are restricted, at least for the first 6 weeks. Your surgeon and corporal therapist will instruct you in your hip precautions. Basically, the precautions are:

• do not turn your toes inward
• do not cross you legs
• do not bend your hip more than 60-90 degrees (when sitting, your knee should not be level with your hip, it should be lower)

If dislocation occurs, call an ambulance to get you to the hospital. Your surgeon will pop the hip back into place. If it happens frequently, a hip brace worn for any months will preclude supplementary dislocations. Hip replacement using the prior coming eliminates the need for hip precautions or restrictions of positions/movements.

Those citizen who are overweight or have weak muscles are more prone to dislocation. Avoid heavy rehearsal that puts too much stress on your new hip (running, playing basketball, tennis, heavy lifting). Instead, participate in activities such as walking, swimming, stationary bike.

Trochanteric problems

Your greater trochanter, a large boney part of your femur, is placed below and to the face of the ball of your hip joint. Many of your large hip muscles anchor on the trochanter, so it's needful for normal hip function.

During lateral coming surgery, the trochanter is detached to passage the hip joint. It's then reattached. If the trochanter does not heal back on the femur bone, it remains as a separate piece. This may effect in pain, weakness, and loss of hip function.

Bowel complications

Constipation often occurs for the first week or so after surgery. This can be caused by medication, immobility, loss of appetite, not drinking sufficient fluids. Stool softeners or enemas may be needed.

Urinary problems

A catheter may be inserted while surgery. Your doctor will order its dismissal as soon as is practical, as catheters pose an increased risk of urinary infection.

Hematoma formation

During surgery, the main areas of bleeding are controlled by cauterization. But some oozing of blood and fluids still occurs, so a drain is attached from the wound to the face of the body. If the drain does not work as planned, a collection of blood and fluids forms in the hip area. This can cause pain, pressure, and inherent infection. Your surgeon may take you back to surgical operation to drain the hematoma.

Loosening of the prosthesis

The harder your bones are, the longer your hip replacement will last. Hard bones originate a stronger bond. citizen with rheumatoid arthritis and osteoporosis are more at risk.

Running and heavy impact activities can also loosen the bond of the implant. Keep your weight down, as this will put more stress on the hip joint. Every pound you gain adds three pounds of force on your hip.

Choose a surgeon who has performed many hip replacements. Talk to some of his old patients to see how they are doing after their hip replacement. Not all surgeons are alike. I have seen a few hip revisions that were needful only because the initial hip replacement was done poorly by the former surgeon.

Pressure sores

In the immediate days after your hip replacement, you may be spending quite a bit more time in bed. Spending a long period of time in one position can lead to pressure sores. Your heels, especially on your surgical operation leg, are very susceptible. A pillow or towel roll under your calves will float your heels and relieve pressure. The elderly are especially prone to pressure sores because their skin is softer and they do not move nearby as well. A close eye should be kept on their heels and tailbone area, and should be regularly repositioned in bed with pillows.

Blood transfusion complications

All blood intended for use in transfusions is screened for Hepatitis B virus, Hepatitis C virus, syphilis, Human T Cell Leukemia virus, and the Aids virus. But infections still occur. Hemolytic Transfusion Reaction occurs due to difference with the donors blood type. The most common cause of Hemolytic Transfusion Reaction is clerical error (mislabelled specimen or improperly identifying the sick person receiving the blood).

If you plan to use your own blood for inherent transfusion, let your doctor know ahead of time so arrangements can be made. Your blood can only be stored for 35 days. collection should begin at least 10-14 days before your surgery. The final collection occurs not later than 5 working days before the surgical operation date. Your blood will be screened as well.

About hip improvement surgery

Most citizen who feel hip replacement surgical operation will never need to replace their artificial joint. But because more and more citizen are having hip replacements at a younger age, the wearing away of the joint face can originate problems. After 15-20 years of wear and tear, replacement (revision surgery) of the artificial joint is becoming more common. improvement surgical operation does not have as good an outcome as the initial surgery.

Consider all the hip replacement complications before you decree on surgery. This is not a unblemished list of risks, as there may be some rare complications not mentioned here.

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Doc... I've Got Severe Pain in the middle of My Shoulder Blades - What's Causing It?

There are many causes of pain in the shoulder blades. Pain between the shoulder blades can occur as a consequent of mundane problems such as working at the computer too long without a break. Some causes though are serious and must be addressed immediately.

Here are some them:

Gall Bladder Pain

Sporadic pains in the middle of the upper abdomen, or just below the ribs on the right side are felt. The pain may spread to the right shoulder or between the shoulder blades. The pain can be accompanied by nausea and vomiting and sometimes excessive gas. The charge can last from a few minutes to two to three hours before getting better. The frequency and severity of attacks is very variable. Attacks can be triggered by eating fatty foods such as chocolate, cheese or pastry. It can be difficult to distinguish the pain from other diseases, such as: gastric ulcer, back problems, heart pains, pneumonia and kidney stones.

Neck source from arthritis or disc disease

This is a normal pain placed in the neck area and may be related with stiffness in the neck muscles. The pain may radiate down to the shoulder or between the shoulder blades. It may also radiate out into the arm, the hand, or up into the head, causing a one-sided or double-sided headache. The muscles in the neck are tense, sore and feel hard to the touch. Acute pain can give rise to abnormal neck posture in which the head is forced to turn to one side; this condition is known as torticollis.
The pain at the base of the skull may be accompanied by a feeling of frailness in the shoulders and arms. There may be a prickly or tingling sensation in the arms and fingers.

Angina Pectoris

Angina pectoris derives from Latin and translates as 'tight chest'. It feels like a heavy, crushing pain or a constricting feeling in the town of the chest behind the breast bone (sternum) or on the left side of the front of the chest. The pain can radiate out to either one or both arms, more often the left. It can be experienced in the throat, jaw, the stomach and, more rarely, between the shoulder blades.

Angina is often brought on by:

o corporal exercise

o psychological stress

o ultimate cold

o a heavy meal.

Once these trigger factors stop, the pain commonly ends quickly, ordinarily within 2 to 10 minutes.

Liver Cancer

Liver cancer, an abnormal cell increase in the liver presents in two ways:

o customary cancer means that the cancer started in the liver

o Secondary cancer of the liver occurs when a cancer starts someplace else and spreads to the liver.

The early warning signs of liver cancer:

A hard lump in the abdomen, below the rib cage on the right side.

Discomfort in the upper abdomen on the right side.

Pain nearby the right shoulder blade, or pain between the shoulder blades.

Yellowish skin color (jaundice)

Abdominal swelling causing a feeling of fullness

Esophageal Cancer

Esophageal cancer appears as a tumor, or an abnormal increase of cells in the esophagus. The esophagus is the food passageway that connects the throat to the stomach.

Esophageal cancer ordinarily does not cause any symptoms until the cancer has advanced to a stage that is too late for productive treatment. The main symptom is strangeness in swallowing food. There is a frequent sensation of food getting stuck in the throat or chest.

Signs of advanced esophageal cancer include:

Pain when swallowing.

Pain in the throat or back, behind the breastbone or pain between the shoulder blades.

Decreased appetite and weight loss.

Hiccups with the feeling of food getting stuck in the throat or chest.

Vomiting and coughing up blood.

Aortic dissection

When the aorta, the major artery foremost from the heart, tears, there can be sudden sharp pain in the spine between the shoulder blades. This is an positive surgical emergency.

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Rib Pain - Why Do My Ribs Hurt?

There isn't a week that goes by in my office that I don't see a person who presents with pain straight through their middle back, painful breathing and ache with movement. The pain can often be very intense. Often they may mistake these symptoms for angina or a heart question and go to the accident room first.

Causes of Rib Pain

Often the cause of a fractured, broken, popped or cracked rib may occur with any known injury or trauma, but may have happened secondary to a bout of hard coughing, or movements that involve a repetitive stress to that region of the body, such as golfing or rowing. In other situations a person who has cancer or an infection could feel what is known as a pathological fracture due to a disease process affecting the bone. Older individuals or osteoporotic persons are also vulnerable or at higher risk of having what is called a fragility fracture, again due to diseased bone structure.

A person can also feel a cracked rib or popped rib from a high velocity impact, or a "crush injury." This is most base in injuries linked to auto accidents and impact sports such as ice hockey, Aussie Rules football, gridiron and rugby.

Symptoms of Rib Pain

In most cases there can be intense pain linked with movement and with deep breathing. Bending and twisting can also be quite painful. Tenderness and pain over the area of involvement.

What To Do If You Have Rib Pain

In the immediate short term, rest and immobilisation are the best things which may supply relief. If you have been complex in an automobile injury, depending on the severity of the injury it is imperative to rule out injury to other organ systems, along with the heart, aorta and lungs.

A persons medical history and corporal exam will supply the doctor with the information indispensable to make a presumptive determination of a broken or fractured rib.

Radiographs (x-rays) can be used to recognize a bone trauma. Cracked ribs, fractured or broken ribs are among the most generally identified pathologies when dealing with chest injuries.

Once a faultless determination has been made, your doctor will be able to decree the appropriate treatment for your exact problem.

Chiropractic Adjustment for Popped Ribs

Depending on the severity of the injury, medical times can vary. Often with a "popped rib," conservative care can be quite effective for providing pain relief and restoring normal function. Low force, exact chiropractic adjustments can be a safe, effective and diplomatic coming to correcting a misaligned rib-spine problem, or a popped rib. Chiropractic instrument adjusting can be a very useful coming to providing relief in individuals who may not be candidates for original by hand chiropractic techniques, such as elderly people, or people who may have other condition issues challenging their problem. We utilise an instrument based coming in many circumstances.

Any treatment recommendations would be based on an literal, determination of your problem. Your chiropractor will escort a appropriate medical history, along with ongoing medical conditions, current medications, traumatic/surgical history, and lifestyle factors. exam may include orthopaedic and neurological tests if indispensable depending on the level of pain, and also x-rays or other industrialized imaging such as magnetic resonance (Mri). Most episodes of popped ribs talk favourably to chiropractic care and decree quickly.

As I mentioned earlier, this record is meant as a guide and anyone experiencing severe pain should consult with their doctor immediately for a faultless and appropriate assessment.

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Massage Therapy for High Blood Pressure

There has been a recent study by Boris Prilutsky, Ma, and Victor Gura, M.D., with regard to the benefits that might be derived from healing massage by those who suffer from hypertension that is caused by arterial hypertension.

In the United States, it is estimated that as many as 70 million habitancy suffer from hypertension. Of that 70 million, only about 8% are diagnosed with an actual cause for the high blood pressure, such as kidney insufficiency, a tumor on the adrenal gland, or narrowing of the aorta. A full 2% are simply diagnosed with necessary hypertension. It is the same condition. It is just a health without a named cause.

The study conducted by Gura and Prilutsky considered that most hypertension patients with musculoskeletal abnormalities can benefit from healing massage. There were only six patients complicated in this study.

Medical massage therapy is defined as a soft-tissue mobilization method. The massage causes an acceleration of blood flow and lymphatic drainage as well as a mechanical breakdown of soft tissue calcifications. The objectives of the pilot study was to conclude either or not the elimination of musculoskeletal abnormalities in the reflex zones would cause the elimination of pain in the neck and upper back as well as headaches, growth range of motion, and cause a allowance in blood pressure.

Cardio examinations and blood pressure readings were taken before the start of treatments and again after they concluded. Each participant received a healing massage medicine every other day for a total of 15 treatments. That was followed by a two-week break, after which someone else course of 15 treatments was administered.

At the end of the study, all participants reported the disappearance of their pain. It was also clear that symptoms were eliminated from reflex zones and blood pressure readings returned to the normal range.

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Blue Toe Syndrome

Blue toe syndrome is the bluish discoloration to toes as a supervene of tissue ischemia (lack of blood flow). The syndrome is caused by the blockage of small vessels that lead into the toes. One or more toes may be affected; in severe cases this can also manifest itself as a multi-organ problem.
There are a few causes of blue toe syndrome but the most tasteless is the breakage of a small piece of arterial plaque commonly from the abdominal aorta-iliac-femoral arterial principles (located in the abdomen and groin area) which then travels down the arterial tree into the small vessels of the foot where it becomes lodged. This is known as an embolism. All tissue distal (in front of) the blockage will then turn a bluish color which represents a lack of oxygen to the tissue.
Generally patients are in their 40s, 50s, 60s, and older. The health can occur insidiously or may be the supervene of abdominal surgery or an invasive vascular procedure or test.

The affected toes become cyanotic but there are other etiologies such as trauma, connective tissue disease like Scleroderma, hypercoagulability of blood as seen in polycythemia vera , atrial fibrillation and Raynauds phenomenon. In Raynauds the fingers will commonly also be complicated and this commonly occurs in younger patients without any known history of atherosclerotic disease.
At the local level, blue toe syndrome may occur in diabetic foot infections and those who have undergone foot surgery.

Blue toe syndrome is surely misdiagnosed because in most cases the larger arteries of the foot are palpable and that directs the doctor away from a diagnosis of occlusive disease.
Treatment is geared towards alleviation of the blockage added up the arterial tree straight through stenting, bypass surgery, or anticoagulant therapy. Vasodilator drugs have no proven effectiveness in rehabilitation of this condition, since this is not a vasospastic disorder.
Mild forms of the disease which sway just the toes have a good diagnosis and commonly subside on their own. It should be noted that sometimes the pain in the toes is disproportional to the extent of involvement of the toes and sufficient analgesics should be prescribed. Multi-systemic forms where the kidney is also commonly affected, the diagnosis is more dubious.
In the foot, should the health not resolve itself there is always the possibility that the condtion will worsen to gangrene and subsequent amputation of the affected toes.

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A Short History of Bullfighting

History of Bullfighting- Origins.

Bullfighting in Spain seems to have its origins while the 8 long centuries of the Spanish
War of Reconquest (711-1492 A.D.) when the knights of both the Moors and
Christians would invent hunting competitions as a respite from killing
each other and they soon realized that of all the prey the Iberian bull
offered the greatest challenge as unlike other animals it adored to die
fighting rather than fleeing.

It seems probable that a nobleman captured a few of these brave beasts
and took them to his village in order to recreate the thrill of the hunt before
his admiring subjects. Thus some remote part of Medieval Spain saw the
origins of what is today the national Spanish spectacle of bullfighting.

The history of bullfighting recalls that the first real bullfight, or
corrida, took place inn 1133 at Vera, Logroño in honour of the coronation
of King Alfonso Viii. From then on they became a beloved pass time at many
important events and continued after the wars of reconquest had finished
offering noblemen an outlet to demonstrate the zeal and daring with which he
defeated the Moors.

King Philip Ii however found the spectacle disgusting and enlisted the
help of Pope Pius V to get it banned by papel decree. This, together with
the growing pleasures to be had at the royal court, resulted in
the nobility giving up their interest in bullfighting but not so the
peasantry who took it enthusiastically to heart and it thus became a symbol
of something categorically Spanish.

By 1726 they were ready to adopt their first bullfighting hero in the from of
Francisco Romero from Ronda. He was a man of humble origins who became the first
professional bullfighter in Spain. With him the corrida industrialized into
more of an art form. He introduced the estoque, sword, and the muleta,
the small cape used in the last part of the fight as it is more easily
wielded.

History of Bullfighting- the contemporary Corrida.

Today's bullfight is much as it was industrialized in the time of Romero.
Normally 6 bulls and three matadors are required for an afternoons
corrida. The three matadors dressed in their trajes de luces (suit of lights)
enter the arena accompanied by their banderilleros and picadors and the
strains of a traditional paso doble. The door to the totil, or bull
pen, is opened and one of the bulls emerges.

The matador greets it with a series of manoeuvres, or passes, with a
large cape; these passes are commonly verónicas, the basic cape
manoeuvre (named after the woman who held out a cloth to Christ on his
way to the crucifixion). Contrary to beloved believe bulls are actually
colour blind and they go for the cape not because it is red but because it
is moving.

The second part of the bullfight is the job of the mounted picadors who
lance the bull, commonly three times. Then a trumpet blows and the
banderilleros on foot move in to place their banderillas ( brightly
coloured barbed sticks) in the beast's shoulders to get it to lower it's head
for the kill. After this a further trumpet sounds which signals
the faena or final phase of the bullfight. The cloth of the muleta is draped over
the estoque and here the matador shows his skill in the passes that he makes.
These consist of the trincherazo which is commonly the opportunity pass performed
on one knee then there is the pase de la firma in which the matador
remains motionless whilst passing the cloth under the bulls nose. The
manoletina involves retention the muleta behind the body and the natural
pass is one in which the danger to the matador is increased as the
estoque is removed from the muleta this reduces the target size and
tempting the bull to fee at the larger object--the bullfighter.

After performing these passes for several minutes while which time the matador
tries to excite the crowd by lively closer and closer to the horns, he finally
and lines up the bull for the kill.

The blade has to pass in the middle of the
shoulder blades and as the space in the middle of them is small the feet of the bull
have to be together as the bullfighter rushes over the horns. The kill
is properly performed by aiming level over the bull's horns and
plunging the estoque in the middle of the withers into the region of the aorta.
This requires necessary skill and discipline, not to mention a certain
amount of raw courage, and for this conjecture is known as "el momento
de la verdad" or the moment of truth.

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